Clinical Rheumatology

, Volume 37, Issue 3, pp 587–595 | Cite as

Role of dual-energy CT in the diagnosis and follow-up of gout: systematic analysis of the literature

  • André Ramon
  • Amélie Bohm-Sigrand
  • Pierre Pottecher
  • Pascal Richette
  • Jean-Francis Maillefert
  • Herve Devilliers
  • Paul OrnettiEmail author
Review Article


The aim of this systematic review was to determine the potential role of dual-energy CT in the diagnosis and follow-up of gout with regard to the Outcome Measures in Rheumatology (OMERACT) filter. A systematic analysis of the literature was conducted using the MEDLINE and Cochrane databases and published abstracts of international congresses, according to the criteria of the OMERACT filter: feasibility, reproducibility, validity versus laboratory (serum urate, MSU synovial fluid aspirate) and other imaging modalities for gout, and its sensitivity to change in patients on urate lowering therapy (ULT). Thirty-two articles were found representing a total of 1502 patients. The data on feasibility showed that the examination took little time and involved low levels of radiation but had current limited availability. Intra- and inter-observer reproducibility was excellent, with intra-class correlation coefficients > 0.9. Validity in comparison with polarized-light microscopy showed good sensitivity and specificity (> 80%). The diagnostic performance was better than that of radiography and conventional CT-scan and at least equivalent to that of ultrasonography. The sensitivity to change varied with effect sizes from 0.05 (low) to 1.24 (high) for decrease in the tophus volume following different ULT in gout patients. Dual-energy CT-scan is a reproducible and accurate imaging modality for the diagnosis of gout, particularly for tophaceous gout (intra- or extra-articular). It can become a second-line imaging modality of choice in cases of diagnostic doubt, such as ultrasonography. Its role remains uncertain in the follow-up of gout patients treated with ULT and needs further clarification.


Dual-energy CT Gout Imaging Psychometric properties Systematic analysis 


Compliance with ethical standards




  1. 1.
    Bardin T, Bouée S, Clerson P, Chalès G, Flipo RM, Lioté F, Perez V, Poiraud T, Schaeverbeke T, Richette P (2016) Prevalence of gout in the adult population of France. Arthritis Care Res 68(2):261–266. CrossRefGoogle Scholar
  2. 2.
    Mccarty DJ, Hollander JL (1961) Identification of urate crystals in gouty synovial fluid. Ann Intern Med 54:452–460CrossRefPubMedGoogle Scholar
  3. 3.
    Richette P, Doherty M, Pascual E, Barskova V, Becce F, Castañeda-Sanabria J, Coyfish M, Guillo S, Jansen TL, Janssens H, Lioté F, Mallen C, Nuki G, Perez-Ruiz F, Pimentao J, Punzi L, Pywell T, So A, Tausche AK, Uhlig T, Zavada J, Zhang W, Tubach F, Bardin T (2017) 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis 76(1):29–42. CrossRefPubMedGoogle Scholar
  4. 4.
    Owens D, Whelan B, McCarthy G (2008) A survey of the management of gout in primary care. Ir Med J 101(5):147–149PubMedGoogle Scholar
  5. 5.
    Dalbeth N, Kalluru R, Aati O, Horne A, Doyle AJ, McQueen FM (2013) Tendon involvement in the feet of patients with gout: a dual-energy CT study. Ann Rheum Dis 72(9):1545–1548. CrossRefPubMedGoogle Scholar
  6. 6.
    Segal JB, Albert D (1999) Diagnosis of crystal-induced arthritis by synovial fluid examination for crystals: lessons from an imperfect test. Arthritis Care Res 12(6):376–380.<376::AID-ART5>3.0.CO;2-5 CrossRefPubMedGoogle Scholar
  7. 7.
    Terslev L, Gutierrez M, Schmidt WA, Keen HI, Filippucci E, Kane D, Thiele R, Kaeley G, Balint P, Mandl P, Delle Sedie A, Hammer HB, Christensen R, Möller I, Pineda C, Kissin E, Bruyn GA, Iagnocco A, Naredo E, D'Agostino MA, OMERACT Ultrasound Working Group (2015) Ultrasound as an outcome measure in gout. A validation process by the OMERACT ultrasound working group. J Rheumatol 42(11):2177–2181. CrossRefPubMedGoogle Scholar
  8. 8.
    Neogi T, Jansen TL, Dalbeth N, Fransen J, Schumacher HR, Berendsen D, Brown M, Choi H, Edwards NL, Janssens HJ, Lioté F, Naden RP, Nuki G, Ogdie A, Perez-Ruiz F, Saag K, Singh JA, Sundy JS, Tausche AK, Vazquez-Mellado J, Yarows SA, Taylor WJ (2015) 2015 gout classification criteria: an American College of Rheumatology/European league against rheumatism collaborative initiative. Arthritis Rheumatol 67(10):2557–2568. CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Nicolaou S, Liang T, Murphy DT, Korzan JR, Ouellette H, Munk P (2012) Dual-energy CT: a promising new technique for assessment of the musculoskeletal system. AJR Am J Roentgenol 199(5 Suppl):S78–S86. CrossRefPubMedGoogle Scholar
  10. 10.
    TRC J (2012) Dual-energy CT: general principles. AJR Am J Roentgenol 199(5 Suppl):S3–S8. Google Scholar
  11. 11.
    Boers M, Brooks P, Strand CV, Tugwell P (1998) The OMERACT filter for outcome measures in rheumatology. J Rheumatol 25(2):198–199PubMedGoogle Scholar
  12. 12.
    Janssens HJ, Fransen J, van de Lisdonk EH, van Riel PL, van Weel C, Janssen M (2010) A diagnostic rule for acute gouty arthritis in primary care without joint fluid analysis. Arch Intern Med 170(13):1120–1126. CrossRefPubMedGoogle Scholar
  13. 13.
    Kienhorst LB, Janssens HJ, Fransen J, Janssen M (2015) The validation of a diagnostic rule for gout without joint fluid analysis: a prospective study. Rheumatol Oxf Engl 54(4):609–614. CrossRefGoogle Scholar
  14. 14.
    Wallace SL, Robinson H, Masi AT, Decker JL, McCarty DJ, Yü TF (1977) Preliminary criteria for the classification of the acute arthritis of primary gout. Arthritis Rheum 20(3):895–900. CrossRefPubMedGoogle Scholar
  15. 15.
    Dalbeth N, Schauer C, Macdonald P, Perez-Ruiz F, Schumacher HR, Hamburger S, Choi HK, McQueen FM, Doyle A, Taylor WJ (2011) Methods of tophus assessment in clinical trials of chronic gout: a systematic literature review and pictorial reference guide. Ann Rheum Dis 70(4):597–604. CrossRefPubMedGoogle Scholar
  16. 16.
    Choi HK, Al-Arfaj AM, Eftekhari A, Munk PL, Shojania K, Reid G, Nicolaou S (2009) Dual energy computed tomography in tophaceous gout. Ann Rheum Dis 68(10):1609–1612. CrossRefPubMedGoogle Scholar
  17. 17.
    Choi HK, Burns LC, Shojania K, Koenig N, Reid G, Abufayyah M, Law G, Kydd AS, Ouellette H, Nicolaou S (2012) Dual energy CT in gout: a prospective validation study. Ann Rheum Dis 71(9):1466–1471. CrossRefPubMedGoogle Scholar
  18. 18.
    Rajan A, Aati O, Kalluru R, Gamble GD, Horne A, Doyle AJ, McQueen FM, Dalbeth N (2013) Lack of change in urate deposition by dual-energy computed tomography among clinically stable patients with long-standing tophaceous gout: a prospective longitudinal study. Arthritis Res Ther 15(5):R160. CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Bongartz T, Glazebrook KN, Kavros SJ, Murthy NS, Merry SP, Franz WB 3rd, Michet CJ, Veetil BM, Davis JM 3rd, Mason TG 2nd, Warrington KJ, Ytterberg SR, Matteson EL, Crowson CS, Leng S, McCollough CH (2015) Dual-energy CT for the diagnosis of gout: an accuracy and diagnostic yield study. Ann Rheum Dis 74(6):1072–1077. CrossRefPubMedGoogle Scholar
  20. 20.
    Huppertz A, Hermann KG, Diekhoff T, Wagner M, Hamm B, Schmidt WA (2014) Systemic staging for urate crystal deposits with dual-energy CT and ultrasound in patients with suspected gout. Rheumatol Int 34(6):763–771. CrossRefPubMedGoogle Scholar
  21. 21.
    Sun Y, Chen H, Zhang Z, Ma L, Zhou J, Zhou Y, Ding Y, Jin X, Jiang L (2015) Dual-energy computed tomography for monitoring the effect of urate-lowering therapy in gouty arthritis. Int J Rheum Dis 18(8):880–885. CrossRefPubMedGoogle Scholar
  22. 22.
    Kiefer T, Diekhoff T, Hermann S, Stroux A, Mews J, Blobel J, Hamm B, Hermann KG (2016) Single source dual-energy computed tomography in the diagnosis of gout: diagnostic reliability in comparison to digital radiography and conventional computed tomography of the feet. Eur J Radiol 85(10):1829–1834. CrossRefPubMedGoogle Scholar
  23. 23.
    Shi D, Xu JX, Wu HX, Wang Y, Zhou QJ, Yu RS (2015) Methods of assessment of tophus and bone erosions in gout using dual-energy CT: reproducibility analysis. Clin Rheumatol 34(4):755–765. CrossRefPubMedGoogle Scholar
  24. 24.
    Dalbeth N, Aati O, Gao A, House M, Liu Q, Horne A, Doyle A, McQueen FM (2012) Assessment of tophus size: a comparison between physical measurement methods and dual-energy computed tomography scanning. J Clin Rheumatol 18(1):23–27. CrossRefPubMedGoogle Scholar
  25. 25.
    Bayat S, Aati O, Rech J, Sapsford M, Cavallaro A, Lell M, Araujo E, Petsch C, Stamp LK, Schett G, Manger B, Dalbeth N (2016) Development of a dual-energy computed tomography scoring system for measurement of urate deposition in gout. Arthritis Care Res 68(6):769–775. CrossRefGoogle Scholar
  26. 26.
    Dalbeth N, House ME, Aati O, Tan P, Franklin C, Horne A, Gamble GD, Stamp LK, Doyle AJ, McQueen FM (2015) Urate crystal deposition in asymptomatic hyperuricaemia and symptomatic gout: a dual energy CT study. Ann Rheum Dis 74(5):908–911. CrossRefPubMedGoogle Scholar
  27. 27.
    Ogdie A, Taylor WJ, Weatherall M, Fransen J, Jansen TL, Neogi T, Schumacher HR, Dalbeth N (2015) Imaging modalities for the classification of gout: systematic literature review and meta-analysis. Ann Rheum Dis 74(10):1868–1874. CrossRefPubMedGoogle Scholar
  28. 28.
    Glazebrook KN, Guimarães LS, Murthy NS, Black DF, Bongartz T, Manek NJ, Leng S, Fletcher JG, McCollough CH (2011) Identification of intraarticular and periarticular uric acid crystals with dual-energy CT: initial evaluation. Radiology 261(2):516–524. CrossRefPubMedGoogle Scholar
  29. 29.
    Zhu L, Wu H, Wu X, Sun W, Zhang T, Ye L, Wang W, Wang J (2015) Comparison between dual-energy computed tomography and ultrasound in the diagnosis of gout of various joints. Acad Radiol 22(12):1497–1502. CrossRefPubMedGoogle Scholar
  30. 30.
    Diekhoff T, Ziegeler K, Feist E, Kiefer T, Mews J, Hamm B, Hermann KG (2015) First experience with single-source dual-energy computed tomography in six patients with acute arthralgia: a feasibility experiment using joint aspiration as a reference. Skelet Radiol 44(12):1573–1577. CrossRefGoogle Scholar
  31. 31.
    Ahmad Z, Gupta AK, Sharma R, Bhalla AS, Kumar U, Sreenivas V (2016) Dual energy computed tomography: a novel technique for diagnosis of gout. Int J Rheum Dis 19(9):887–896. CrossRefPubMedGoogle Scholar
  32. 32.
    Gruber M, Bodner G, Rath E, Supp G, Weber M, Schueller-Weidekamm C (2014) Dual-energy computed tomography compared with ultrasound in the diagnosis of gout. Rheumatol Oxf Engl 53(1):173–179. CrossRefGoogle Scholar
  33. 33.
    Hu H-J, Liao M-Y, Xu L-Y (2015) Clinical utility of dual-energy CT for gout diagnosis. Clin Imaging 39(5):880–885. CrossRefPubMedGoogle Scholar
  34. 34.
    Wu H, Xue J, Ye L, Zhou Q, Shi D, Xu R (2014) The application of dual-energy computed tomography in the diagnosis of acute gouty arthritis. Clin Rheumatol 33(7):975–979. CrossRefPubMedGoogle Scholar
  35. 35.
    Breuer GS, Bogot N, Nesher G (2016) Dual-energy computed tomography as a diagnostic tool for gout during intercritical periods. Int J Rheum Dis 19(12):1337–1341. CrossRefPubMedGoogle Scholar
  36. 36.
    Baer AN, Kurano T, Thakur UJ, Thawait GK, Fuld MK, Maynard JW, McAdams-DeMarco M, Fishman EK, Carrino JA (2016) Dual-energy computed tomography has limited sensitivity for non-tophaceous gout: a comparison study with tophaceous gout. BMC Musculoskelet Disord 17(1):91. CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Araujo EG, Bayat S, Petsch C, Englbrecht M, Faustini F, Kleyer A, Hueber AJ, Cavallaro A, Lell M, Dalbeth N, Manger B, Schett G, Rech J (2015) Tophus resolution with pegloticase: a prospective dual-energy CT study. RMD Open 1(1):e000075. CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Gervaise A, Teixeira P, Villani N, Lecocq S, Louis M, Blum A (2013) CT dose optimisation and reduction in osteoarticular disease. Diagn Interv Imaging 94(4):371–388. CrossRefPubMedGoogle Scholar
  39. 39.
    Glazebrook KN, Kakar S, Ida CM, Laurini JA, Moder KG, Leng S (2012) False-negative dual-energy computed tomography in a patient with acute gout. J Clin Rheumatol 18(3):138–141. CrossRefPubMedGoogle Scholar
  40. 40.
    Mallinson PI, Coupal T, Reisinger C, Chou H, Munk PL, Nicolaou S, Ouellette H (2014) Artifacts in dual-energy CT gout protocol: a review of 50 suspected cases with an artifact identification guide. Am J Roentgenol 203(1):W103–W109. CrossRefGoogle Scholar
  41. 41.
    Terslev L, Gutierrez M, Christensen R, Balint PV, Bruyn GA, Delle Sedie A, Filippucci E, Garrido J, Hammer HB, Iagnocco A, Kane D, Kaeley GS, Keen H, Mandl P, Naredo E, Pineda C, Schicke B, Thiele R, D'Agostino MA, Schmidt WA, OMERACT US Gout Task Force (2015) Assessing elementary lesions in gout by ultrasound: results of an OMERACT patient-based agreement and reliability exercise. J Rheumatol 42(11):2149–2154. CrossRefPubMedGoogle Scholar
  42. 42.
    Dalbeth N, Doyle AJ (2012) Imaging of gout: an overview. Best Pract Res Clin Rheumatol 26(6):823–838. CrossRefPubMedGoogle Scholar
  43. 43.
    Sun Y, Ma L, Zhou Y, Chen H, Ding Y, Zhou J, Wei L, Zou H, Jiang L (2013) Features of urate deposition in patients with gouty arthritis of the foot using dual-energy computed tomography. Int J Rheum Dis 18(5):560–567. CrossRefPubMedGoogle Scholar
  44. 44.
    Mallinson PI, Reagan AC, Coupal T, Munk PL, Ouellette H, Nicolaou S (2014) The distribution of urate deposition within the extremities in gout: a review of 148 dual-energy CT cases. Skeletal Radiol 43:277–281. CrossRefPubMedGoogle Scholar
  45. 45.
    Carr A, Doyle AJ, Dalbeth N, Aati O, McQueen FM (2016) Dual-energy CT of urate deposits in costal cartilage and intervertebral disks of patients with tophaceous gout and age-matched controls. Am J Roentgenol 206(5):1063–1067. CrossRefGoogle Scholar
  46. 46.
    Komlosi P, Wintermark M (2017) Dual energy computed tomography applications for the evaluation of the spine. Neuroimaging Clin N Am 27(3):483–487. CrossRefPubMedGoogle Scholar

Copyright information

© International League of Associations for Rheumatology (ILAR) 2018

Authors and Affiliations

  • André Ramon
    • 1
  • Amélie Bohm-Sigrand
    • 1
  • Pierre Pottecher
    • 2
    • 3
  • Pascal Richette
    • 4
    • 5
  • Jean-Francis Maillefert
    • 1
    • 6
  • Herve Devilliers
    • 7
    • 8
  • Paul Ornetti
    • 1
    • 6
    Email author
  1. 1.Department of RheumatologyDijon University HospitalDijonFrance
  2. 2.Department of Radiology, Section of Musculoskeletal Imaging and InterventionDijon University HospitalDijonFrance
  3. 3.LE2I UMR CNRS 6306, Arts et MétiersUniversity of BurgundyDijonFrance
  4. 4.INSERM U1132 and University Paris-DiderotParisFrance
  5. 5.Department of RheumatologyHopital LariboisiereParisFrance
  6. 6.INSERM UMR1093-CAPS, Bourgogne Franche-Comté UniversityDijonFrance
  7. 7.Department of Internal MedicineDijon University HospitalDijonFrance
  8. 8.CIC INSERM 1432, Centre Hospitalier Universitaire de DijonDijonFrance

Personalised recommendations